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1 Group Health Options, Inc.: Options Idaho Group Conversion Coverage Period: 7/1/2012 1/1/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Group Conversion Plan Type: POS This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? $0 See the chart starting on page 2 for your costs for services this plan covers. Are there other You don t have to meet deductibles for specific services, but see the chart deductibles for specific No. starting on page 2 for other costs for services this plan covers. services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? Yes, $5,000 individual innetwork/$10,000 family in-network $8,000 individual innetwork/$16,000 family in-network This plan has no out-of-pocket limit. No. Yes. See or call for a list of in-network providers. Yes. Call for more information. Yes. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Not applicable because there s no out-of-pocket limit on your expenses. The chart starting on page 2 describes specific coverage limits, such as limits on the number of office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays for different kinds of providers. This plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the specialist. Some of the services this plan doesn t cover are listed on page 4. See your policy or plan document for additional information about excluded services. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 1 of 8 C20126

2 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use in-network providers by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your cost if you use an In-network Out-of-network Limitations & Exceptions Primary care visit to treat an injury or illness $20 co-pay 50% co-insurance none Specialist visit $20 co-pay 50% co-insurance none $20 co-pay for 50% co-insurance Other practitioner office visit manipulative for manipulative Manipulative therapy limited to $1,000 therapy and therapy and per calendar year. naturopathy naturopathy Preventive care/screening/immunization No charge Not covered Services must be listed on the Group Health well-care schedule. Diagnostic test (x-ray, blood work) $20 co-pay 50% co-insurance none High end radiology imaging services Imaging (CT/PET scans, MRIs) $20 co-pay 50% co-insurance such as CT, MR and PET require preauthorization. 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition Services You May Need Formulary generic drugs Formulary brand drugs Your cost if you use an In-network $10 co-pay $10 co-pay Out-of-network 70% benefitspecific coinsurance 70% benefitspecific coinsurance Limitations & Exceptions Covers up to a 30-day supply Covers up to a 30-day supply More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Non-formulary brand/generic drugs Not covered Not covered none Mail-order drugs Member pays the prescription drug cost share Available when dispensed through the Group Health designated mail order service Covers up to a 30-day supply Facility fee (e.g., ambulatory surgery center) No charge No charge none Physician/surgeon fees $200 co-pay $400 co-pay none Notify Group Health within 24 hours Emergency room services $100 co-pay $100 co-pay of admission, or as soon thereafter as medically possible. Emergency medical transportation $100 co-pay $100 co-pay none Urgent care $20 co-pay 50% co-insurance none Facility fee (e.g., hospital room) none Physician/surgeon fee 20% co-insurance 50% co-insurance 3 of 8

4 Common Medical Event If you have mental health, behavioral health, or substance abuse needs If you are pregnant Services You May Need Your cost if you use an In-network Out-of-network Limitations & Exceptions Mental/Behavioral health outpatient services 50% co-insurance 70% co-insurance none Mental/Behavioral health inpatient services 70% coinsurance/admit Substance use disorder outpatient services 50% co-insurance 70% co-insurance none Substance use disorder inpatient services 70% coinsurance/admit Preventive services related to prenatal Prenatal and postnatal care No charge 50% co-insurance and preconception care are covered as Delivery and all inpatient services preventive care. Notify Group Health within 24 hours of admission, or as soon thereafter as medically possible. 4 of 8

5 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your cost if you use an In-network Out-of-network Limitations & Exceptions Home health care No charge 20% co-insurance Requires preauthorization Rehabilitation services $20 co-pay/ outpatient / inpatient 50% coinsurance/ outpatient / inpatient Habilitation services Skilled nursing care Durable medical equipment $20 co-pay/ outpatient / inpatient 20% benefitspecific coinsurance 50% coinsurance/ outpatient / inpatient 50% benefitspecific coinsurance Requires preauthorization. none Hospice service 20% co-insurance 50% co-insurance Requires preauthorization. Eye exam $20 co-pay Not covered Limited to children under age 12. Glasses No charge Not covered Limited to $75 per calendar year for children under age 12. Dental check-up $20 co-pay Not covered Limited to one exam every 12 months for children under age of 8

6 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Non-emergency care when traveling outside Acupuncture Hearing aids the U.S. Bariatric surgery Infertility treatment Private-duty nursing Cosmetic surgery Long-term care Routine foot care Dental care (Adult) Most coverage provided outside the United Routine eye care (Adult) Glasses States. See Weight loss programs Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Chiropractic (if prescribed for rehabilitation purposes) Your Rights to Continue Coverage: Federal and State laws may provide protections that allow you to keep this health insurance coverage as long as you pay your premium. There are exceptions, however, such as if: You commit fraud The insurer stops offering services in the State You move outside the coverage area For more information on your rights to continue coverage, contact the insurer at You may also contact your state insurance department at Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: The Insurance Consumer Hotline at or access to a page to the same office: Or the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or Language Access Services: Spanish (Español): Para obtener asistencia en Español, llame al Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does not provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? In order for certain types of health coverage (for example, individually purchased insurance or job-based coverage) to qualify as minimum essential coverage, the plan must pay, on average, at least 60 percent of allowed charges for covered services. This is called the minimum value standard. This health coverage does meet the minimum value standard for the benefits it provides. To see examples of how this plan might cover costs for a sample medical situation, see the next page. 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $5,440 Patient pays $2,100 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $0 Co-pays $500 Co-insurance $1,400 Limits or exclusions $200 Total $2,100 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $4,220 Patient pays $1,180 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $0 Co-pays $900 Co-insurance $200 Limits or exclusions $80 Total $1,180

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. 8 of 8

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